Medical History

pateint first name

patient last name

Doatienes your child have any of the following medical conditions?

Acid Reflux ADD/ADHD Anemia Anesthetic allergy Anxiety ASD Asthma Autism Beckwith-Wiedemann Syndrome Blood Disease Breath holding spells Bruise/Bleed Easily CAMK2B Related Disorder Cancer Celiac Child Abuse Chromosomal Abnormality-Trisomy 8 Cleft Lip/Palate Congential Hypothyroidism Croup Delayed gross motor Depression Developmental Delay Diabetes Down Syndrome Ear tubes Eczema ehlers-danlos syndrome eosinophilic esophagitis Epilepsy or Seizures Excessive Bleeding Factor 11 deficiency failure to thrive Fainting Febrile Seizures Gastric Pull Up GERD Global developmental delay Growth Abnormalities Head Injury Headaches Hearing Concerns Heart Abnormalities Heart Murmur diagnosed a year ago being montitored by family doctor heart transplant hemi hyperplasia Hyperthyroidism Hypoglycemic Hypotonia Immune Disorders Immune Dysfunction kawasaki disease Keratosis Pilaris Kidney Disease Language Delay Laryngomalacia Liver Disease Malignant Hyperthermia Mast cell activation syndrome Mental Illness Microdeletion in 15 chromosome OCD only has one kidney Osteogenesis Imperfecta Philadelphia Positive B cell ALL Premature Pulmonary Stenosis Reactive Airways Disease renal vein thrombosis, low protein c renal vein thrombosis, low protein z Senosry Processing Disorder Sickle Cell Anemia/Trait Sleep Apnea Speech Concerns strabismus - left eye Strabismus (eye wanders in diff. directions) STXBP1 Disorder Tachycardia Tumour velopharangyl insufficiency Von Willembrand Disorder

Any other health conditions not listed above?

Yes No

Has your child ever been hospitalized for any illness or surgery?

Yes No

Is your child allergic to any of the following?

Amoxicillin Anesthetic Aspirin Codeine Dairy Epinephrine Erythromycin Food Colouring/Dye Gluten Ibuprofen Latex Local Anesthetic Metals Novacaine peanuts Penicillin Seasonal allergies sesame Sulfa Tree nuts

Any other allergies not listed above? *

Yes No

Please specify other medications, pills or drugs not listed above

Name of Pediatrician / Family Doctor

Is there any other information about your child's health we should know?

What is your primary concern about your child's oral health?

How often are your child's teeth brushed?

How often does your child's teeth get flossed?

What type of toothpaste does your child use?

Flouride-free With Flouride No Toothpaste

Has your child been examined or treated by another dentist?

Yes No

May we contact your child's previous dentist to obtain records?

Yes No

Were x-rays taken of the teeth or jaws?

Yes No

How do you expect your child to respond to dental treatment?

Is there anything else we should know before treating your child?

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to patient's health. It is my responsibility to inform Smile Squad Kids Dental of any changes in medical status.

Draw your signature into the box below. *

Clear

Relationship to the patient *

Name if not the patient *